Parent Low Income 2014-2015

Parent Low Income 2014-2015

Student ID #

Student Name

Your parent's reported income for 2013 was unusually low. Please indicate how your household expenses were paid from January 1, 2013 to December 31, 2013. Please enter amounts for all items. If the item does not apply indicate "zero".

Expenses for 2013

Housing

Rent/Mortgage

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Utilities

Electricity/Gas

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Water/Sewer

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Transportation

Car Note

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Insurance

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Fuel

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Personal

Food

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Medical

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

Daycare

Amount per Month $

Number of Months

Yearly Total $

From what source was this paid?

TOTAL EXPENSES

Yearly Total $

Please explain in the case that an item that was not required for all 12 months or was not required at all.

VPLOW4

Income for 2013

Student Name

Earned income from W-2s, business or farm

Amount per Month $

Number of Months

Yearly Total $

Unemployment Compensation

Amount per Month $

Number of Months

Yearly Total $

TANF, AFDC, etc.

Amount per Month $

Number of Months

Yearly Total $

Food Stamps

Amount per Month $

Number of Months

Yearly Total $

Housing Assistance

Amount per Month $

Number of Months

Yearly Total $

Social Security Income

Amount per Month $

Number of Months

Yearly Total $

Disability Income

Amount per Month $

Number of Months

Yearly Total $

Workman's Compensation

Amount per Month $

Number of Months

Yearly Total $

Financial Aid/Scholarships

Amount per Month $

Number of Months

Yearly Total $

Other

Amount per Month $

Number of Months

Yearly Total $

TOTAL INCOME

Yearly Total $

If the total amount of expenses is greater than your total income please explain how this expense was provided for.

Total amount

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